I've had my first week of "radiation vacation," more officially known as Diagnostic Imaging rotation. It's another 3 week rotation, for which I'll get a "bonus" partial week before Christmas.
And, yeah. There's not that much to say about it. Basically we sit around the radiology department, waiting for requests for radiographs to come in. Sometimes we walk over to the patient wards to retrieve a dog or cat; sometimes the animal is brought to us. Sometimes the pet is sedated or anesthetized for radiographs; sometimes they don't need to be; sometimes they aren't sedated but should be. Sometimes we take abdominal rads or extremities (quite a few stifles), but mostly we take "met checks" (3-view thoracic radiographs).
Sometimes we take radiographs pretty much non-stop for a period of several hours. And then there are days like yesterday, when we took 3 sets of rads in 5 hours. Blechh.
On the one hand, it's nice to have a chill rotation requiring arrival at 8 am and from which we usually get to leave at 4, but always by 5. However, I'm already anticipating an extreme worsening of my current level of boredom by the time another 2.5 weeks have passed. Oh, well -- should give me some time to polish up my resume and start job-hunting!
Saturday, December 3, 2011
NAVLE, shmAVLE
I took the North American Veterinary Licensing Exam, aka NAVLE, aka "boards" 2 days ago. And it went pretty well. I've spent about 3 months doing practice questions and practice exams regularly on VetPrep, and I felt like I was pretty well prepared.
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
Sunday, November 27, 2011
Groundbreaking news
I did NOT get called in yesterday.
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
Saturday, November 26, 2011
Anesthesia: Almost done!
It's been a long, long month of Anesthesia.
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Tuesday, November 8, 2011
Anesthesia on-call
Last night was my second on-call shift for Anesthesia. Here's my schedule for the last 2 days:
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Saturday, November 5, 2011
Anesthesia, Week 1
I've just finished my first of several weeks of Anesthesia. It's typically a 3 week rotation, but since mine falls over Thanksgiving, I get an extra 3 regular days plus a "bonus" fourth on-call shift.
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Thursday, October 27, 2011
"Fleas make everything worse," or "Why I hate bureaucracy"
Today I had another cardiology patient whose main problem wasn't really cardiac-related. (See: The case of Mr. Beagle.)
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
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